Provider Demographics
NPI:1659338655
Name:BLACKSTONE VALLEY CENTER FOR INTERNAL MEDICINE, INC
Entity Type:Organization
Organization Name:BLACKSTONE VALLEY CENTER FOR INTERNAL MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GREIGSTONE
Authorized Official - Middle Name:MONTGOMERY
Authorized Official - Last Name:YEARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-762-2535
Mailing Address - Street 1:191 SOCIAL ST
Mailing Address - Street 2:SUITE 840
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-3240
Mailing Address - Country:US
Mailing Address - Phone:401-762-2535
Mailing Address - Fax:401-762-2858
Practice Address - Street 1:191 SOCIAL ST
Practice Address - Street 2:SUITE 840
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-3240
Practice Address - Country:US
Practice Address - Phone:401-762-2535
Practice Address - Fax:401-762-2858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9020093Medicaid